A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

Comparative effectiveness of various orbital decompression techniques in treating thyroid-associated ophthalmopathy: a systematic review and meta-analysis

BACKGROUND

In thyroid-associated ophthalmopathy (TAO), orbital decompression is a critical surgical approach for functional and aesthetic reasons. Meanwhile, the presence of surgical complications, especially the new onset of primary gaze diplopia, also influences postoperative patient satisfaction. This research investigates the effectiveness and potential risks associated with different orbital decompression in patients with TAO.

METHODS

Systematic searches were conducted to identify pertinent studies from PubMed, Embase, and the Cochrane Library databases. The search was completed on October 11, 2023. And after retrieval, the publication dates of the articles included in the analysis ranged from January 1, 2008, to February 22, 2023. The overall postoperative outcomes were determined using random-effects meta-analyses with corresponding 95% confidence intervals (CI). A network meta-analysis was performed to integrate both direct and indirect evidence. The primary outcomes were defined as the status of exophthalmos and the new onset of primary gaze diplopia.

RESULTS

From 1,538 identified records, 87 studies were selected, encompassing 5102 patients and 8,779 procedures. The studies reported varying degrees of exophthalmos reduction based on different surgical techniques: -3.46 mm (95% CI -3.76 to -3.15 mm) for fat removal orbital decompression, -4.02 mm (95% CI -5.14 to -2.89 mm) for the medial wall technique, -3.89 mm (95% CI -4.22 to -3.55 mm) for the lateral wall technique, -5.23 mm (95% CI -5.69 to -4.77 mm) for the balanced wall technique, -3.91 mm (95% CI -4.37 to -3.46 mm) for the infero-medial wall technique, and - 5.80 mm (95% CI -6.47 to -5.13 mm) for the three-wall technique. The incidence of new-onset primary gaze diplopia was reported in 31 studies involving 214 out of 2001 patients, resulting in a weighted proportion of 0.11 (95% CI 0.06-0.14). Notably, the lowest rates were associated with the lateral approach and fat removal orbital decompression, with pooled proportion (95% CI) rates of 3% (1-6) and 3% (2-4), respectively, suggesting that these two techniques may be more effective in preventing the occurrence of this complication during the postoperative period.

CONCLUSIONS

This meta-analysis establishes that orbital decompression is a beneficial and safe surgical approach. While this study enhances the evidence hierarchy for orbital decompression in treating TAO, it requires further validation through larger, prospective, and randomized studies with long-term follow-up periods.

Initial implementation of surgical guide design utilizing digital medicine for lateral orbital decompression surgery

This study aimed to assess the feasibility of utilizing a surgical guide, designed through digital medical technology, in lateral orbital decompression surgery. METHODS: In total, 18 patients with thyroid-associated ophthalmopathy (TAO), who underwent orbital balance decompression surgery at the Affiliated Eye Hospital of Nanchang University between September 2018 and August 2022, were included. Orbital CT scanning was performed on all patients with TAO, and Mimics 21.0 software was used to reconstruct a three-dimensional model of the orbit based on the CT data. The osteotomy guide plate for lateral orbital decompression surgery was designed using 3-matic 13.0 software, adhering to the criteria of surgical effectiveness and safety. The surgical positioning guide was designed using Geomagic Wrap 21.0. Once printed, the surgical guide was sterilized with low-temperature plasma and applied during surgery. Of the nine patients treated using a surgical navigation system, three cases experienced cerebrospinal fluid leakage complications during the procedure, and two exhibited inadequate bone removal along the lateral wall. In contrast, among the nine patients treated with surgical guides, no intraoperative cerebrospinal fluid leakage or evidence of insufficient lateral wall bone removal was observed, highlighting a statistically significant distinction between the two cohorts (p = 0.046). Postoperative improvements were notable in best-corrected visual acuity (BCVA) and exophthalmos for patients afflicted with extremely severe TAO. The surgical guide, designed with digital medical technology, has been shown to be an effective and secure auxiliary tool in lateral orbital decompression surgery. It not only aids in reducing the incidence of intraoperative complications, but also enhances the accuracy and safety of surgery. These improvements offer robust support for continued exploration in this field within clinical practice.

The effect of rim-off deep lateral orbital decompression on the lateral rectus shape and oculomotor balance

PURPOSE

The purpose of the study was to measure the effect of rim-off deep lateral decompression for Graves orbitopathy on the lateral rectus muscle path and oculomotor balance.

METHODS

Retrospective analysis of the medical records and pre- and postoperative computed tomography scans of 34 orbits of 23 patients who underwent deep lateral decompression alone. The oculomotor balance of these 23 patients was measured with the alternate cover test and prisms before and after surgery. Bezier functions were used to measure the postoperative path of the lateral rectus in all decompressed orbits.

RESULTS

Deep lateral decompression induced a curvilinear deformation of the lateral rectus. There was no significant correlation between the position of the point of maximum muscle displacement and the size of the residual lateral wall. The changes in the lateral rectus path had no adverse effects on the oculomotor balance of the patients.

CONCLUSIONS

The location of the curvilinear deformation of the lateral rectus does not depend on the residual segment of the lateral wall. The changes of the lateral rectus path have no deleterious effect on the oculomotor balance.

Piezosurgery versus Conventional Cutting Techniques in Craniofacial Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Despite its increasing use in craniofacial surgery, the evidence for piezosurgery over conventional bone-cutting techniques has not been critically appraised. The purpose of this systematic review and meta-analysis was to identify and assess the evidence that exists for the use of piezosurgery in craniofacial surgery.

METHODS

A systematic review was undertaken using a computerized search. Publication descriptors, methodologic details, and outcomes were extracted. Articles were assessed using the methodologic index for nonrandomized studies and Cochrane instruments. Random effects meta-analysis was completed.

RESULTS

Thirty-nine studies were included. Most studies were published within the past 5 years (51.3 percent) and were randomized controlled trials (56.4 percent). The mean age of patients was 27 years (range, 0.2 to 57 years), and the mean sample size was 44 (range, 12 to 180). Meta-analysis revealed that compared to conventional instruments, piezosurgery had a lower postoperative incidence of sensory disturbance, principally in mandibular procedures (OR, 0.29; 95 percent CI, 0.11 to 0.77; p = 0.01) and pain at postoperative day 3 (mean difference, -0.86; 95 percent CI, -1.20 to -0.53; p < 0.01). There was no statistically significant difference in operating room time (mean difference, 8.60; 95 percent CI, -1.27 to 18.47; p = 0.80) or osteotomy time (mean difference, 0.35; 95 percent CI, -2.99 to 3.68; p = 0.84). Most studies were clinically homogenous (92 percent) and of high quality based on the methodologic index for nonrandomized studies instrument (84 percent). Few studies had domains at high risk of bias based on the Cochrane instrument (28.6 percent).

CONCLUSIONS

Piezosurgery has considerable benefits when compared to conventional instruments. Future studies should investigate its cost-effectiveness and benefits in terms of blood loss, edema/ecchymosis, and patient satisfaction.

Infraorbital Nerve Decompression for Chronic Post Traumatic Neuralgia: A Novel Approach and Review of the Safety and Efficacy of Piezoelectric Surgery on Soft Tissues and Nerves

ABSTRACT

Chronic post traumatic infraorbital nerve (ION) hyperesthesia is a rare complication of orbital floor fractures. Surgical decompression of the ION has been reported to relieve chronic post traumatic infraorbital neuralgia. This case report describes a novel approach for ION decompression in a patient who suffered from chronic infraorbital neuralgia associated with a healed displaced orbital floor fracture. We used an intraoperative 3D image-guided navigation system to accurately localize the fracture site and employed piezoelectric surgery for nerve decompression. We further review the literature on the safety and efficacy of piezoelectric surgery on soft tissue and nerves.

Use of an Ultrasonic Aspirator in Removal of an Orbital Rim Hemangioma

Intraosseous hemangiomas are rare bony neoplasms that infrequently develop in the calvarium or facial bones. Due to their highly vascular nature, biopsy or resection of these tumors can present a surgical challenge, with reports of significant blood loss during tumor resection. Traditional surgical resection of intraosseous hemangiomas often includes the use of high speed oscillating or sagittal saws. Ultrasonic aspirators, which spare adjacent soft-tissue structures and minimize blood loss, have been successfully used in resection of firm soft tissue masses of the orbit; however, this technology has not been demonstrated in the treatment of a vascular tumor in the orbit. The authors present the case of a 37-year-old woman who presented with an intraosseous hemangioma at the left inferior orbital rim and maxilla; the mass was successfully resected with the aid of a Sonopet Ultrasonic Aspirator bone knife. The knife allowed for simultaneous emulsification and cautery of the bone encasing the mass with low risk to sensitive surrounding tissue.

Surgical management of the orbit in thyroid eye disease: lateral orbital decompression

PURPOSE OF REVIEW

Lateral orbital wall decompression is one of many well established techniques available to surgeons in management of patients with clinically significant thyroid eye disease (TED). Several different surgical approaches have been described in the literature and are reviewed herein.

RECENT FINDINGS

Lateral orbital wall decompression remains a popular technique for surgical management of TED, with a recent American Society of Ophthalmic Plastic and Reconstructive Surgery survey showing that 22.6% of respondents preferred a single-wall procedure, with 36.8% of that subset preferring lateral wall decompression alone. Surgical techniques for lateral orbital wall decompression differ based on several steps, such as the incisional approach, whether to take an ab-interno versus ab-externo approach, and whether to remove orbital fat to achieve further decompression. In addition, technological advances have produced an array of tools available to the orbital surgeon to achieve efficient and accurate bone removal.

SUMMARY

Lateral orbital wall decompression for TED, despite being an older technique, remains a popular and well established procedure for orbital decompression. Though no randomized controlled clinical trial supports one decompression technique over another for TED, lateral orbital wall decompression offers many benefits such as its ease of access and visualization of the orbital space.

Orbital wall decompression in the management of Graves' orbitopathy: a systematic review with meta-analysis

PURPOSE

To systematically review outcomes of orbital bony wall decompression for Grave's orbitopathy according to the surgical approach.

METHODS

A systematic search for studies published in "Ovid MEDLINE", "Web of Science" and "Embase" of patients with surgical treatment of Grave's orbitopathy was performed. The overall postoperative change in Hertel exophthalmometry was calculated by random-effect meta-analysis model with 95% confidence interval (CI).

RESULTS

A total of 33 studies, including 1686 patients and 2946 procedures, were included. The weighted mean Hertel value overall reduction was - 4.56 mm (95% CI - 5.05 to - 4.07 mm). According to surgical techniques the reduction was - 4.36 mm (95% CI - 5.22 to - 3.50) for infero-medial technique, - 4.88 mm (- 5.68 to - 4.08) for medial-lateral technique, - 4.32 mm (- 4.80to - 3.84) for lateral technique, - 5.45 mm (- 6.16 to - 4.74) for three-wall technique and - 3.47 mm (- 5.81 to - 1.12) for medial technique. The overall rate of new-onset of primary gaze diplopia was reported in 23 studies. The included procedures were 653 and results were heterogeneous (heterogeneity: Q = 78.8 df = 22, I2 = 72.09%, p < 0.01). The pooled proportion (95% CI) rate of new-onset of primary gaze diplopia was 12% (7-16).

CONCLUSION

Our metanalysis highlights that orbital bony wall decompression represents an effective surgical procedure. The three wall approach was associated with the best results in terms of exophthalmos reduction. Data suggest that an exclusive lateral approach may help to avoid the new-onset of primary gaze diplopia during the postoperative period.

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

PURPOSE

To systematically review the literature on the deep lateral orbital decompression (DLD).

METHODS

The authors searched the MEDLINE, Lilac, Scopus, and EMBASE databases for all articles in English, Spanish, and French that used as keywords the terms orbital decompression and lateral wall. Two articles in German were also included. Data retrieved included the number of patients and orbits operated, types of the approach employed, exophthalmometric and horizontal eye position changes, and complications. The 95% confidence intervals (CI) of the mean Hertel changes induced by the surgery were calculated from series with 15 or more data.

RESULTS

Of the 204 publications initially retrieved, 131 were included. Detailed surgical techniques were analyzed from 59 articles representing 4559 procedures of 2705 patients. In 45.8% of the reports, the orbits were decompressed ab-interno. Ab-externo and rim-off techniques were used in 25.4% and 28.8% of the orbits, respectively. Mean and 95% CI intervals of Hertel changes, pooled from 15 articles, indicate that the effect of the surgery is not related to the technique and ranges from 2.5 to 4.5 mm. The rate of new onset of diplopia varied from zero to 8.6%. Several complications have been reported including dry eye, oscillopsia, temporal howling, lateral rectus damage, and bleeding. Unilateral amaurosis and subdural hematoma have been described in only one patients each.

CONCLUSIONS

The low rate of new-onset diplopia is the main benefit of DLD. Prospective studies are needed to compare the rate of complications induced by the 3 main surgical techniques used.

Bony Orbital Decompression in Patients with High Myopia and Pseudoexophthalmos

INTRODUCTION

High myopic eyes grow in length (> 0.35 mm/dpt) more than in height and width leading to a disturbing unilateral exophthalmos in patients with anisomyopia and - more rarely - a bilateral exophthalmos in high myopia affecting both eyes. Secondary consequences are sicca symptoms and painful eye mobility due to a large bulbus in a too small bony orbit. The aim of the work was to evaluate the effectiveness of bony orbital compression in cases of high myopia.

MATERIAL AND METHODS

Four patients underwent bony orbital decompression between the years 2012 and 2019. Two of the patients received lateral and two of them balanced (medial endonasal endoscopic and lateral) decompression. The decompression effect, complications and the influence of decompression on eye position and motility were evaluated.

RESULTS

Significant decompression effect was achieved in all patients. As a result, symmetry was restored in all unilaterally affected patients. No complications occurred. The lateral decompression had a positive effect on the preexisting convergent strabismus (reduction of the "eso" position, neutral to the vertical deviation). The carefully dosed medial decompression did not lead to any change of the horizontal position in one patient and in the other exotropic patient it resulted in a 10 pdpt of "exo" reduction without developing an "eso" position.

DISCUSSION

The bony orbital decompression provides a sufficient decompression effect in the four patients to reduce the myopic pseudoexophthalmos. The alignment anomalies associated with a high myopia ("heavy eye") was favourably influenced by the lateral decompression.

First Use of a New Robotic Endoscope Guiding System in Endoscopic Orbital Decompression

PURPOSE

Over the last years, robot-assisted surgery gained in importance in head and neck surgery. In our study, we used a new robotic endoscope guiding system in patients undergoing endoscopic balanced orbital decompression. The aim of the study is to evaluate the feasibility and benefit of a robotic arm in endoscopic orbital surgery.

METHODS

The Medineering Robotic Endoscope Guiding System is a robotic arm designed for holding an endoscope during interventions. An endoscope equipped with a 4K camera was attached at the tip of the robotic arm and placed in the surgical field. The surgeon controlled the movements of the endoscope with foot pedal. Eight patients underwent balanced endoscopic orbital decompression showing typical symptoms of Graves' orbitopathy preoperatively. Balanced decompression was performed via a combined approach transnasally and laterally via a small skin incision.

RESULTS

Attaching the endoscope to the robotic guiding system and placing it in the nasal cavity were relatively simple procedures. Setup time was less than 10 minutes. Tool motion and control using the foot pedal were comfortable and adequately precise. Movements of the attached endoscope inside the nose were feasible and allowed 2-hand surgery. The patients did not show any adverse events or complications.

CONCLUSION

The Medineering Robotic Endoscope Guiding System seems to be a safe and effective support in endoscopic skull base surgery especially for orbital decompression, thus allowing 2-hand or even 4-hand settings. To the best of our knowledge, this is the first study describing the successful application of a robotic system in orbital surgery.